Farmacia Hospitalaria (English Edition)最新文献

Introduction

Various international studies have shown that fludarabine is effective, safe, and efficient for treating B-cell chronic lymphocytic leukaemia (B-CLL). The purpose of the present study was to carry out a cost-minimization analysis for 2 alternative forms of fludarabine (oral and intravenous) used to treat B-CLL in Spain.

Methods

The presence of clinical evidence about the treatment equivalence of the 2 options being compared (oral fludarabine vs intravenous fludarabine) led us to carry out a costminimization analysis. A pharmacoeconomic model was constructed to compile data from the literature and experts’ opinions in order to determine the use of health resources associated with the treatment; unit costs were obtained from Spanish databases. The analysis contemplated 2 perspectives: that of the national health service, which includes only direct health costs, and the social perspective, which also includes the indirect costs that result from loss of productivity.

Results

Although fludarabine in its oral form has a higher purchase price than generic intravenous fludarabine does, increased administration costs for the latter, which is used in hospitals, mean that oral fludarabine use produces total savings of #euro1908 and #euro1292 for single-drug therapy and combined therapy with cyclophosphamide, respectively. Including indirect costs increased the savings associated with the oral form of the drug.

Conclusions

In B-CLL patients, treatment with oral fludarabine has a lower cost than treatment with intravenous fludarabine, in both single-drug therapy and combined therapy. Various sensitivity analyses confirmed these results and showed that oral fludarabine should be the treatment of choice for B-CLL in Spain, unless contraindicated.

Dabigatran is the first available oral direct thrombin inhibitor anticoagulant. Absorption of the prodrug, dabigatran etexilate and its conversion to dabigatran is rapid (peak plasma concentrations are reached 4–6 h following surgery, and a further 2 h later). Its oral bioavailability is low, but shows reduced interindividual variability. Dabigatran specifically and reversibly inhibits thrombin, the key enzyme in the coagulation cascade. Studies both in healthy volunteers and in patients undergoing major orthopaedic surgery show a predictable pk/pd profile that allows for fixed-dose regimens. The anticoagulant effect correlates adequately with the plasma concentrations of the drug, demonstrating effective anticoagulation combined with a low risk of bleeding. Dabigatran is mainly eliminated by renal excretion (a fact which affects the dosage in elderly and in moderate-severe renal failure patients), and no hepatic metabolism by cytochrome P450 isoenzymes has been observed, showing a good interaction profile.

Rivaroxaban will probably be the first available oral factor Xa (FXa) direct inhibitor anticoagulant drug. It produces a reversible and predictable inhibition of FXa activity with potential to inhibit clot-bound FXa. Its pharmacokinetic characteristics include rapid absorption, high oral availability, high plasma protein binding and a half-life of aprox. 8 h. Rivaroxaban elimination is mainly renal, but also through faecal matter and by hepatic metabolism. Although the drug has demonstrated moderate potential to interact with strong CYP3A4 inhibitors, it does not inhibit or induce any major CYP450 enzyme.

Introduction

The objective of this study is to analyse the appropriateness and characteristics of drug dose calculation for hospitalised, morbidly obese patients.

Methods

Retrospective, descriptive study of dose calculations for drugs prescribed to hospitalised, morbidly obese patients in a tertiary hospital in 2007. The recommendations prepared by the Pharmacy division are used as a standard.

Results

We included 62 patients. The mean number of medications prescribed per patient was 12.1 (4–39), and an average of 2.4 (1–10) are listed in the recommendations. A total of 135 drugs were prescribed. Dose calculations for 81 of the above (60%) coincided with recommendations and 54 (40%) did not; there were 51 cases of underdosing and three cases of overdosing.

Discussion

Improper dosing was detected for prescriptions in the systemic antibiotic and antithrombin drug groups, with underdosing being more common than overdosing.

Objectives

To evaluate the quality of the pharmacotherapeutic recommendations included in the Integrated Care Processes (PAIs regarding its initials in Spanish) of the Andalusian Ministry of Health, published up to March 2008, through the design and validation of a tool.

Methods

The assessment tool was designed based on similar instruments, specifically the AGREE. Other criteria included were taken from various literature sources or were devised by ourselves. The tool was validated prior to being used. After applying it to all the PAIs, we examined the degree of compliance with these pharmacotherapeutical criteria, both as a whole and by PAIs subgroups.

Results

The developed tool is a questionnaire of 20 items, divided into 4 sections. The first section consists of the essential criteria, and the rest make reference to more specific, non essential criteria: definition of the level of evidence, thoroughness of information and definition of indicators. It was found that 4 of the 60 PAIs do not contain any type of therapeutic recommendation. No PAI fulfils all the items listed in the tool, however, 70 % of them fulfil the essential quality criteria established.

Conclusions

There is a great variability in the content of pharmacotherapeutical recommendations for each PAI. Once the validity of the tool has been proved, it could be used to assess the quality of the therapeutic recommendations in clinical practice guidelines.

Introduction

A bezoar is a hard mass of undigested foreign matter found in the gastrointestinal system. The most common type is the phytobezoar, which is composed of vegetable fibres. There is no current consensus as to its treatment. Three cases of phytobezoars treated with cellulase are described.

Patients and method

Case 1: patient with large gastric phytobezoar. Initial treatment with nasogastric cola drink lavages was ineffective. Subsequent treatment with cellulase was successful. Case 2: patient with gastric phytobezoar who was treated with cellulase and metoclopramide. Definitive fragmentation was performed with the endoscopy technique. Case 3: patient with large intestinal phytobezoar. The patient was treated by endoscopic lysis with partial success. Subsequent treatment with cellulase led to complete disintegration. In all the cases, cellulase was administered in pure form by nasogastric tube, and none of the patients suffered adverse effects.

Conclusions

Treatment with cellulase is based on the enzymatic degradation of the bezoar. It has been shown to be effective as the treatment of choice in earlier studies with few patients. This agent seems to be a good alternative for patients with large phytobezoars.

Introduction

The direct transfer of the results of pharmaco-economic studies between countries may not be suitable if the proper adaptations are not made to take into account differences in treatment patterns, resource use, and costs from country to country.

Objective

To estimate the cost in Spain of treating anaemia secondary to chronic renal failure with darbepoetin alpha or epoetin alpha from a review and analysis of available current information. In addition, the role of the route of administration as a main driver of the cost will be analysed.

Method

Population: patients with chronic renal failure induced anaemia. Data: Medline and Embase search of studies directly comparing erythropoiesis stimulating agents. Analysis: Cost minimization analysis from the perspective of a hospital pharmacy department. The main outcome chosen was the difference between the average cost per patient undergoing a 30-day treatment with epoetin alpha versus darbepoetin alpha.

Results

a) Haemodialysis: changing from epoetin alpha to darbepoetin alpha is associated with a cost reduction of 8.67%; 95% CI, −1.34 to 17.92 (€uro17.48; 95% CI, −2.70 to 36.13); probabilistic analysis showed that the use of darbepoetin alpha could be associated with a costsaving probability of 94.9%. The IV administration yielded a decrease in costs of about 16.00%; 95% CI, −2.38 to 36.77 (€uro41.78, 95% CI: −6.21 to 96.04); b) Pre-dialysis: darbepoetin alpha is associated with a cost reduction of about 11%–32%.

Conclusions

The use of darbepoetin alpha for the treatment of chronic renal failure induced anaemia (haemodialysis and pre-dialysis) shows higher cost efficiency than epoetin alpha in Spain; these differences increase with IV administration.

Refeeding syndrome is a complex syndrome that occurs as a result of reintroducing nutrition (oral, enteral, or parenteral) to patients who are starved or malnourished. Patients can develop fluid-balance abnormalities, electrolyte disorders (hypophosphataemia, hypokalaemia, and hypomagnesaemia), abnormal glucose metabolism, and certain vitamin deficiencies. Refeeding syndrome encompasses abnormalities affecting multiple organ systems, including neurological, pulmonary, cardiac, neuromuscular, and haematological functions. Pathogenic mechanisms involved in the refeeding syndrome and clinical manifestations have been reviewed. We provide suggestions for the prevention and treatment of refeeding syndrome. The most important steps are to identify patients at risk, reintroduce nutrition cautiously and correct electrolyte and vitamin deficiencies properly.

Objective

To analyse the characteristics and cost of medical prescriptions given upon discharge from the casualty department, as well as the savings made by making substitutions with generis drugs or other equivalent pharmaceutical products in a third level hospital.

Methods

Six hundred sixty-nine patients were chosen using a cluster sample with a sub-sample. The following variables were considered: a) analysis of the prescription (medication quantification, active ingredients and most prescribed therapeutic groups, and possibility of prescribing generis drugs); b) calculation of cost and saving estimate (price to public and equivalent products); and c) prescription quality (adherence to the guide and percentage of products of high therapeutic use.)

Results

Three hundred seventy of the 669 patients received medication when they were discharged, with an average of 1.7 per patient. Six hundred twenty-nine products were prescribed, 16% due to their active ingredient, with 37.53% generic products available. The main active ingredients prescribed were paracetamol, ibuprofen, and omeprazole amounting to 26.70% of the total prescribed and the therapeutic groups that were highlighted were locomotor apparatus, the nervous system, the digestive apparatus, and metabolism with 69.39% of the total. Ninety-two point eighty-four pecent of the prescriptions adhered to the pharmacotherapeutic guide and 98.41% were of high therapeutic use. The annual cost of prescribed medication was €1 013 778 and the saving made by generic product substitution and a programme of therapeutic equivalents was €145 971.

Conclusions

A prescription based on its active ingredients and a therapeutic and generis substitution produce a significant saving both for the patient and for the hospital.

Objective

To identify drug interaction databases (DID) and assess the quality of their structures.

Method

A search was made of the literature for DID and a series of exclusion and structural quality criteria were defined (at least 4 quality criteria: classification according to severity, classification according to level of evidence, bibliographical reference data, description of clinical management, and 11 criteria used for weighting). The level of compliance of every DID with the criteria defined was analysed, together with the level of compliance of each criteria in each DID.

Results

A total of 54 DID were identified, 30 of which complied with exclusion criteria and 15 of which did not meet the minimum criteria. The rest of the criteria were evaluated in 9 DID: Botplus and Medinteract (100%), SEFH Guide, Lexi-interact and Medscape (89%), Hansten (83%), Micromedex and Stockley (78%), Drug Interactions Facts (68%). Ninety-two percent of the DID describe the mechanism of action, 87% classify the information according to the active ingredient, 75% do not state they have any conflict of interest, classify according to level of severity, have electronic format, and are easy to search. A total of 67% are specific DID, 62% are classified according to level of evidence, contain bibliographical references, and describe clinical management.

Conclusions

A third of the DID comply with the minimum criteria. Differences were observed in the level and compliance criteria among Spanish and foreign DID. Some of the main DID used as references in the bibliography have significant structural defects: no web presentation, no multi-check function and others.

Objective

To establish the relationship between the adherence to ARVT and the clinical situation and detect those factors which relate to the lack of adherence.

Method

Observational study on HIV patients who had attended the Pharmacy Service in Hospital de Navarra between February and May 2005. The SMAQ questionnaire and pharmacy dispensing records were used to assess adherence to treatment. Socio-demographic variables and other factors which could influence adherence were recorded. Statistical analysis was carried out using the SPSS programme, version 14.0.

Results

No concordance was noted between the 2 measurements of adherence, although there was an association between the viral load and compliance, irrespective of the method used. The questionnaire recorded a higher percentage of non-adhering female patients, substance users and psychiatric patients. Non-adhering patients indicated more frequently factors which made taking the medication difficult. The multivariate analysis showed that the lack of a suitable social-familial environment negatively influenced the adherence level, according to the SMAQ questionnaire, and that the high number of tablets per dose was related to the lack of adherence according to the pharmacy dispensing records.

Conclusions

Patients who adhere to ARVT have a lesser risk of virological failure. An unsuitable social-familial environment and the complexity of treatment are associated with a lack of adherence. The method of using dispensing records should be combined with a patient interview to define the factors which reduce adherence and to propose intervention strategies.